To: Sonoma County Board of Supervisors
Department or Agency Name(s): Department of Health Services
Staff Name and Phone Number: Tina Rivera, 707-565-4774
Vote Requirement: Informational Only
Supervisorial District(s): Countywide
Title:
Title
Tiered Advanced Life Support/Basic Life Support Ground Ambulance Services Update - Informational Report Only
End
Recommended Action:
Recommended action
Receive an Informational Report on the development and implementation of Tiered Advanced Life Support/ Basic Life Support Ground Ambulance Service.
end
Executive Summary:
Tiered Response is a framework by which emergency medical dispatchers assess the criticality of a 911 call and determine whether to allocate an ALS unit or a BLS unit. It is considered a more effective and efficient use of emergency medical services (EMS) resources and is increasingly being adopted throughout the country.
On November 2, 2021, the Board of Supervisors reviewed changes and approved the release of a Request for Proposal (RFP) for the exclusive provider of emergency ground ambulance services. The RFP included the implementation of tiered response.
In an effort to continue ground ambulance services during the RFP process, on May 24, 2022, the Board of Supervisors authorized the Director of Health Services to execute an amendment to extend an agreement with American Medical Response West (AMR) for emergency ground ambulance services until January 15, 2024. The amendment included a rate increase and the authorization to implement Tiered Advanced Life Support (ALS)/Basic Life Support (BLS) Emergency Medical Services Response within the Exclusive Operating Area-1 (EOA-1), the area within and around Santa Rosa. The amendment called for the implementation of Tiered Response within the EOA.
During the May, 2022 meeting, the Board of Supervisors, in addition to other stakeholders, expressed concern about implementation and called on Coastal Valleys EMS Agency to work with stakeholders to craft an implementation plan for Tiered Response. A Tiered Response workgroup has convened for the last 18 months to design, implement, and assess a pilot phase, and to design a full implementation model based on their findings.
Since May 2022, the responsibility for delivering emergency medical services transportation in EOA-1 transitioned from AMR to Sonoma County Fire District (SCFD). On June 6, 2023 the Board of Supervisors authorized the Director of Health Services to execute a 5-year contract for emergency ground ambulance service in EOA-1 with Sonoma County Fire District. On January 15, 2024, the franchise for SCFD to operate exclusively in EOA-1 began and on the same date, the Sonoma County began implementation of Tiered Response within EOA-1.
This report provides a summary of the substantial progress and collaborative efforts made by the Tiered Response workgroup to arrive at this point.
Discussion:
Emergency Medical Services (EMS) are the system by which residents of an area can dial an emergency number such as 911 and receive critical pre-hospital care and transport in the event of an accident or illness. In Sonoma County, these services are provided by a mix of public and private providers who operate in EMS response zones or districts. In places where 911 call volume is large, this network of providers should be coordinated so that an appropriate number of providers respond to a call, given the scale of the need. Competition in the moment over 911 calls is not considered beneficial. It creates the possibility that many resources are tied up trying to compete for one call while another call has no resources to respond. The provision of critical pre-hospital care involves the delivery of complex and sometimes risky medical procedures that can be life or limb saving when performed well or harmful if performed poorly. EMS providers need a coordinated system in which to operate with policies and procedures that address the allocation of resources, the quality of medical care and the interoperability and compatibility of communications equipment so that providers can share information effectively.
For these reasons, the state of California passed the EMS Act within the California Health and Safety Code and established Local EMS Agencies (LEMSAs) to serve as these critical referees and safeguards over the quality and safety of medical care. The state is divided into several locally controlled LEMSAs, and they are, in turn, regulated by a central state body - California EMS Authority (EMSA). The EMS Act provides the rules and authorizes the promulgation of state regulations and local policies which EMSA and LEMSAs use to coordinate and regulate local EMS systems.
In Sonoma County, the LEMSA functions are assigned to the Department of Health Services (DHS). The Department Director is identified as the head of the LEMSA. The Department Director delegates work responsibility to Coastal Valleys EMS Agency (CVEMSA), a part of DHS, which provides the statutorily required services to both Sonoma County and Mendocino County. CVEMSA assesses the needs of various regions of the county and the services available to identify zones of responsibility and outlines these in its annual EMS plan. In addition, LEMSAs, may, from time to time, identify a need to establish an exclusive operating area. The EMS Act provides the rules for how such areas are to be established and how service rights within these areas can be allocated. EMSA has determined that unless a provider has existing rights and obligations to provide EMS services in a response zone, the right to provide these services must be competitively bid out by the LEMSA. In exchange for an exclusive right to operate within an EOA, the winning bidder accepts the responsibility to respond to all urgent calls regardless of location, ability to pay or other potential means by which a provider might discriminate or differentiate in the allocation of resources.
Sonoma County has two EOAs - one comprises the city of Santa Rosa and neighboring communities including Cotati, Rohnert Park, Kenwood, and Sebastopol, and another comprising the area around Windsor and Healdsburg. The provider of ground advanced life support (ALS) services in EOA-1 was, for the previous 32 years, American Medical Response, a division of Global Medical Response. On June 6, 2023 the Board of Supervisors authorized the Director of Health Services to execute a 5-year contract for emergency ground ambulance service in EOA-1 with Sonoma County Fire District (SCFD). The recommendation was based on the results of a competitive request for proposal process. On January 15, 2024, the franchise for SCFD to operate exclusively in EOA-1 began and on the same date, Sonoma County began implementation of Tiered Response within EOA-1. The current provider in EOA-1 is Sonoma County Fire District (SCFD).
Tiered Response is a framework by which emergency dispatchers assess the criticality of a 911 call and determine whether to allocate an ALS unit or a Basic Life Support (BLS) unit. It is considered a more effective and efficient use of emergency medical services (EMS) resources and is increasingly being adopted around the country. Until 2023, all emergency 911 calls had an ALS ambulance dispatched in Sonoma County.
Stakeholders and the Board expressed concern about immediate implementation of Tiered Response within the EOA since the county had no recent experience with such a system that involved 911 dispatch of BLS units in areas served by ALS. The Board called on CVEMSA to work with stakeholders to craft an implementation plan for Tiered Response.
A workgroup comprised of staff from CVEMSA and representatives from public fire agencies, private ambulance providers, paramedic base hospital and local EMS training programs based at institutions of higher education was convened beginning in April of 2022 in response to this directive and has met for the last 23 months under the leadership of the Coastal Valleys EMS Agency Medical Director. The group worked together collaboratively and productively to design and implement a Tiered Response pilot phase, assessed the pilot phase data, and designed a full implementation model informed by their findings. This remainder of this report shares the progress and details of this workgroup’s efforts.
The Tiered response workgroup convened its first meetings in the late April of 2022. It held 11 meetings between that time and February of 2023. It reviewed models of Tiered response and discussed the risks and benefits of moving to such a model. This was a collaborative process throughout and marked by a shared commitment to the safety of the transition to a new model and a desire to assure that EMS resources were used most appropriately and efficiently within the system. Due to the concerns associated with deploying a new model in which no county provider had direct local experience, the group decided to err on the side of caution and deploy a conservative model initially as a pilot test and confine the pilot to EOA - 1, the exclusive operating area around Santa Rosa and limit it to the city’s boundaries. The workgroup consisted of members from the Emergency Medical Care Council (EMCC), the Redwood Empire Communications and Dispatch Center (REDCOM) Board, the Dispatch Operations Area Group (DOAG), and the Coastal Valleys’ Medical Advisory Committee.
This pilot phase for Tiered Response began in January of 2023, after the workgroup worked with REDCOM, CVEMSA and others to design an implementation plan. In an emergency dispatch center such as REDCOM, emergency 911 calls that require an ambulance response are rated though an internationally accepted Emergency Medical Dispatch (EMD) system based on urgency and criticality. This can determine the type of unit dispatched and the urgency with which that unit travels - with sirens and lights or without. These calls are typically classified as follows:
|
Type |
Severity |
Response Style and Time |
|
Alpha |
Low priority; code 2 |
Urgent, no lights or siren |
|
Bravo |
Mid Priority; code 2 |
Emergent, lights and sirens first due resource |
|
Charlie |
Possibly Life Threatening; code 3 |
Emergent, lights and sirens |
|
Delta |
Life Threatening; code 3 |
Emergent, lights and sirens |
|
Echo |
Full arrest or Imminent Death; code 3 |
Emergent, lights and sirens |
The pilot model called for the continued, immediate dispatch of an ALS ambulance regardless of the type of call within the city of Santa Rosa. The dispatcher would then work to dispatch a BLS unit to the same call if the call was an Alpha or Bravo call (see table above). Staff at the scene would assess the situation and determine, based on the patient’s severity of illness or injury, whether to transport them to a medical facility via the ALS unit or the BLS unit. This system was instituted for six months. After the initial six months, the stakeholder group reviewed the call data to identify how the system had worked, what impact it had on services, and to compare the decisions providers made in the field to the determinants and conditions diagnosed by EMS providers for the patient. The purpose of the analysis was to determine whether it would be safe to dispatch a BLS unit rather than an ALS unit in some instances. Doing this is thought to be a better, and less expensive use of resources since BLS operating costs and charges are typically lower than those of ALS units. There was a data subgroup which met three times to examine the data and propose ways of evaluating it. The overall Tiered Response workgroup met another 13 times in this second phase to review this data and discuss the implications for the next phase of the pilot.
Several conclusions were drawn from this data. First, in about half the total instances (3,353 total calls) a BLS unit did not arrive on scene after dispatch in time to transport a patient. 44.7 percent of the units were cancelled enroute. Of the 2,057 instances where a BLS unit arrived on scene, in only 1,023 instances was the patient transferred with the BLS unit. In the 1,034 instances in which a patient was not transported with a BLS unit, a third of these resulted in no transport at all and about 60 percent resulted in an ALS transport to an Emergency Room.
The committee wanted to better understand which kinds of calls resulted in a BLS transport, whether the outcome was affected in any way by transporting the patient via a BLS unit, which kinds of calls were not transported by BLS, and why these calls resulted in an ALS transport. The hope initially had been that most Alpha and Bravo calls would be safe to transport by BLS. However, the fact that fewer than 30 percent of the total calls did end up with a BLS transport suggested that there were limiting factors the workgroup needed to understand better before identifying a set of factors that would determine if only a BLS unit could be dispatched. Several potential hypotheses were explored to understand the reasons for these outcomes.
The group looked more closely at the Alpha and Bravo calls that resulted in an ALS transport to identify the factors that led to this decision. It pulled data from medical records on the nature of a patient’s illness or injury, matched it with the dispatch data, and sought to understand the decision making in the field. The data and analysis were shared with the full workgroup, which concluded that it would be extremely challenging to identify a set of Alpha and Bravo calls where a BLS unit alone could be dispatched, since there were so many varying results from decisions made in the field.
At this point, a workgroup member suggested that the Tiered Response dispatch system for Fresno be examined to see if it could be imported and applied to Sonoma County. Beginning with a tried and tested set of criteria from an existing California system was thought to be a more elegant solution to the challenge of creating a BLS dispatch ruleset from scratch. A subgroup led by the Medical Director of CVEMSA including the Medical Director of Sonoma County Fire, and representatives from various fire districts, REDCOM and paramedic base hospital ER departments reviewed the Fresno system and each of the call types that would result in a BLS dispatch. They identified which of those could be assigned a BLS response and which would continue to receive an ALS response. The group decided that it would be safest to deploy this model within EOA-1 only and only in areas where paramedic first responders, who arrive with a simultaneously dispatched Fire Department group, were also sent to the scene of the 911 call. In this way, a skilled paramedic would always be on scene to step in and help during a transport in a BLS unit if it proved necessary. The group proposed testing this Sonoma-specific model as the next phase in the pilot of a Tiered Response system. Data would continue to be collected and reviewed by a subgroup of the workgroup, who would reconstitute as an Implementation and Oversight Team. Acting under the direction of the CVEMSA Medical Director, this team would use the data to adjust which calls were sent BLS and which were to be sent ALS. They would also assess whether Tiered Response may be safely rolled out to other areas of the county where paramedics (i.e., ALS staff) were available on local fire apparatus and at what point this system could be implemented in places where paramedics were not part of the local fire department system. There is no timeline set for the expansion of this system at this time; expansion will be dependent on the quality and amount of data generated by this test phase and the confidence of stakeholders, particularly the CVEMSA Medical Director, in the safety of expansion.
The entire process was marked by high professionalism, a dedication to honest inquiry, and a commitment to finding the best solution for the County. Mutual respect was shown on all sides and despite some challenging topics, the intellectual exchange was of the highest professional level.
Phase 2 of the system launched on January 16, 2024 concurrent with the switch of ALS providers in EOA-1. CVEMSA and its partners will continue to collect data and review it to assure patient safety, positive outcomes, and effective use of 911 resources. Future reports on the impacts of this new system innovation can be provided at the Board’s request.
An Implementation and Monitoring Workgroup consisting of a diverse set of 10-15 system leaders has been convened by CVEMSA to review the data from calls dispatched as Tiered Response within EOA. The group is meeting on a weekly basis. So far, the system appears to be working well. It has been complicated somewhat by the simultaneous change-over in providers within EOA-1. Currently, about 85% of the population of the County is being served by Tiered Response. The group will meet consistently to iron out wrinkles in the system and monitor for sentinel events such as a BLS unit being dispatched to a call which becomes critical and in need of ALS staffing during the transport. In such instances, a paramedic from the local fire department is expected to ride along in the ambulance to provide care but the system is designed to avoid these occurrences. Transportation to a large Emergency Department from the remainder of the county would involve longer transport times and greater risks to patient safety, particularly if an ALS paramedic is not on the scene. Many of the outlying fire departments do not have ALS paramedics. CVEMSA does not have a current timeframe for this expansion but expects to have a more defined timeline in the next 4-6 months.
Strategic Plan:
This item directly supports the County’s Five-year Strategic Plan and is aligned with the following pillar, goal, and objective.
Pillar: Healthy and Safe Communities
Goal: Goal 5: Continue to invest in public safety so that residents and visitors feel safe in our community.
Objective: Objective 2: Better integrate services and handoffs within the Safety Net departments.
Racial Equity:
Was this item identified as an opportunity to apply the Racial Equity Toolkit?
Yes
This item was identified as an opportunity to apply the Racial Equity Toolkit. After further review and given that this item is an informational update and not a policy decision, staff recommend that the toolkit be applied at a more appropriate time or when more data from the implementation of this initiative is available to support an equity analysis.
Prior Board Actions:
On May 24, 2022, the Board of Supervisors authorized the Director of Health Services to execute an amendment to extend an agreement with American Medical Response West for emergency ground ambulance services to January 15, 2024, in addition to a rate increase and authorizing a phased-in implementation of Tiered ALS/BLS Emergency Medical Services Response.
Fiscal Summary
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Narrative Explanation of Fiscal Impacts:
There are no fiscal impacts associated with this item.
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Narrative Explanation of Staffing Impacts (If Required):
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Attachments:
None
Related Items “On File” with the Clerk of the Board:
None